医院管理与医疗保险的关系与利益探讨

Discussion on relationship and interest between hospital management and medical insurance

医疗保险机构和医院这对矛盾的两个主体,由于其目标的一致性、功能的统一性、运行机制的依赖性、资源的互补性及趋利性、对立统一的长期性,只有紧密配合,互相沟通,互相理解,互惠互利,确立正确的合作伙伴关系,才能真正成为矛盾的统一体。两者之间相互影响,医疗保险有利于医院管理规范化、对医院的经营管理产生深远影响、有利于提升医院的信誉和形象,同时医院管理对医保改革也起到推动作用,包括:控制不合理费用,提高基金使用效率、抑制道德损害行为,扩大社会支持面、在一定程度上依赖于定点医院的合作。双方建立合作伙伴关系需要处理好的主要问题,包括:医疗保险设计思路由控制调整为合作、建立有效的沟通机制、建立双方定期召开协商会议制度,形成谈判机制、制定科学合理的费用支付体系、医院适应医保改革的举措等。同时,医院还要与商业保险公司建立良好的合作关系。

Medical insurance and hospital is a pair of contradiction subjects. Because of the consistence of goals, unity of functions, operation independence, resources complementarily and profit tendeney and/he long term of unity of opposites, the two subjects should work closely with each other, communication and understanding with each other to create correct friendship and shape correct contradiction relationship. Medical insurance and hospital impacts each other. Medical insurance can promote hospital healthy management and improve hospital brand and identity. Hospital can promote medical insurance reform such as control irrational medical expenditure, increase medical insurance funds efficiency, reduce moral hazards and widen medical insurance coverage. Problems impaeling friendship relationship construction inelude changing medical insurance management conception from eontrolling to cooperate, establishing effective communication mechanism, fixed meeting system to confer with each other, shaping negotiate mechanism, scientific and effective pay mechanism, measures fit to medieal insurance reform. Meanwhile, hospital and commercial health company should create good partnership.